EDITORIAL

Critically Ill Obstetric Patients and Feto-maternal Outcome

Balasaheb D Bande

A b s t r ac t​
Reduction in the maternal mortality ratio (MMR) continues to be a worldwide challenge. With repeated analytical studies done over decades,
it has become possible to identify the significant contributors to this challenge. Right from low socioeconomic status to the availability of
recent technological advances, many factors need attention and prioritization. Obstetric hemorrhage remains an important cause followed by
hypertensive disorders of pregnancy and sepsis. In this issue of IJCCM, Miglani et al. have highlighted the various levels of the delays, which
are significant contributors to the high MMR. In other preventive strategies, efforts will be needed to improve patient education, infrastructure,
availability of trained manpower, blood storage facilities, timely referrals, transport facilities, etc., at peripheral levels. In the tertiary care centers,
there is an increased need for trained manpower in critical care, the obstetric medical emergency team as a new concept, aggressive teamwork
in intensive care unit (ICU) and operation theaters, the use of advanced technologies and newer drugs, etc. It will remain a tough challenge to
reduce global MMR to 70 per 100,000 live births, as per plans by the United Nations, by the year 2030.
Keywords: Feto-maternal outcome, Maternal mortality ratio, Obstetric critical care.
Indian Journal of Critical Care Medicine (2020): 10.5005/jp-journals-10071-23650

O v e r v i e w​ Department of Anaesthesiology and Critical Care, KEM Hospital, Pune,

The reduction in the maternal mortality ratio (MMR) has remained a
worldwide challenge, especially in developing and underdeveloped
countries. About 1,600 women die worldwide daily due to
pregnancy-related complications.1 In this issue of IJCCM, Miglani et
al., in their prospective observational study, have tried to analyze
the factors contributing to the unfavorable fetomaternal outcome
in critically ill pregnant women. It is well known that, in this younger
subset of patients, morbidity and mortality are highly preventable,
provided we recognize the attributable factors. According to the
NFHS-3 (National Family Health Survey of India, 2005–2006), the
main reasons related to high MMR in India are:2
• Trained personnel not being available for deliveries.
• Poor awareness of antenatal care,
• Deficient postnatal care.
India stands second in the world in an absolute number of
maternal deaths, though 1990 onward, there has been a significant
decline, i.e., from 400 to 130 per 100,000 live births in 2016. 3
Considering the magnitude of the problem, there have been
aggressive attempts to minimize the MMR. Over the years, there
have been remarkable advances in training the personnel as well
as increasing the education level of the patients, but the challenge
continues. In a recently carried out study by Horwood et al.3 on
1.9 million pregnant women from 9 empowered action group
states in India, similar conclusions were drawn, besides specifically
highlighting the timely availability of emergency care. The article by
Miglani et al. in the current issue also highlights the different levels
of delays and their impact on the fetomaternal outcome.
Clinical Profile of the C r i t i c a l ly I l l
P r e g n a n t W o m e n​
Besides logistic and socioeconomic factors, a higher prevalence
of systemic morbidity in parturients, in terms of peripartum
hemorrhage, hypertensive disorders of the pregnancy, etc., seems
to be causing a higher incidence of peripartum complications,
Maharashtra, India
Corresponding Author: Balasaheb D Bande, Department of
Anaesthesiology and Critical Care, KEM Hospital, Pune, Maharashtra,
India, Phone: +91 9822051593, e-mail: drbandebd@hotmail.com
How to cite this article: Bande BD. Critically Ill Obstetric Patients
and Feto-maternal Outcome. Indian J Crit Care Med 2020;24(11):
1005–1007.
Source of support: Nil
Conflict of interest: None
compromising the fetomaternal outcome. This was highlighted
in a recent study of more than 10,000 deliveries, by Tasneem
and Sharma. 4 They found that anemia prevailed in 25.5% of
cases. Among 110 critically ill, out of 10,208 parturients, the main
indications for intensive care unit (ICU) admission in their study
were disseminated intravascular coagulation (DIC) (39%), eclampsia
(22.7%), peri partum hemorrhage (PPH) (21.8%), hemolysis elevated
liver enzymes and low platelets syndrome (HELLP) (13.6%), acute
renal failure (10.1%), acute respiratory distress syndrome (ARDS)
(3.6%), and sepsis (3.2%). Of these, 72.7% of patients needed
ventilatory support, 60.1% needed inotropic support, 28.2% needed
surgical interventions, and 10.9% needed dialysis. Of the critically ill
pregnant women, maternal mortality was 12.8% and fetal mortality
was 40.8%.4 In another recent study of 91 pregnant ICU patients
(26 per 1,000, i.e., 2.6%) by Sailaja and Renuka,5 almost similar
findings were noted. Being a tertiary care center, most patients were
postpartum (84.6%) and referred to ones (63.8%). The major causes
for the ICU admissions were hypertensive disorders (24.2%) and
obstetric hemorrhage (23.1%). Mechanical ventilation was needed
in 54.9%, blood transfusion in 46%, vasopressor therapy in 22%, and
dialysis in 9.9% of patients. Mortality was 9.9% and sepsis was the
cause in a third of the patients. The cesarean rate was about 47.3%
and emergency laparotomy was needed in 14.3%.5
Over a decade, there seems to be a mild shift of etiology of
the maternal morbidity and mortality from obstetric hemorrhage

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 Critically Ill Obstetric Patients and Feto-maternal Outcome
being most common before and prevalence of the hypertensive
pregnancy disorders to be on the rise in recent years. In 2011,
Gupta et al.6 reported obstetric hemorrhage cases in obstetric ICU
admissions to be 62.5% and hypertensive disorders of pregnancy
as 16.6%. In one retrospective analytical study in 2014, Ashraf et al.7
reported obstetric hemorrhage as a cause of ICU admission in 51%
cases and pregnancy-related hypertension in 11% cases. A few years
later in 2018, Bahadur et al.8 reported obstetric hemorrhage cases in
ICU to be 38.6% and those of hypertensive disorders of pregnancy
to be 28.6%. In another recent analytical study of obstetric ICU
admissions in 2019, Veerabhadrappa et al.9 reported proportions of
obstetric hemorrhage and hypertensive disorders of pregnancy to
be 30 and 33.3%, respectively. All these studies were from medical
college hospitals, which essentially receive patients from lower
socioeconomic strata.
B e t t e r F e to - m at e r n a l O u tco m e ,
P r e v e n t i v e S t r at e g i e s​
Lower socioeconomic status, lack of education, and poor antenatal
care, for a long time, are known to be associated factors for poor
fetomaternal outcome.10 WHO statement once recorded that
“there is a story behind every maternal death or life‑threatening
complications and understanding the lessons to be learnt can
help to avoid such outcomes”.11 Thus to minimize the severity,
one needs to go to the root cause of problems associated with
poor fetomaternal outcomes. Multiple studies and reports have
highlighted the root causes and hence the preventability, in case
those are improved upon.12–16 Thus, it is essential that maternal
and child healthcare programs are implemented effectively and
priority is also given to the overall socioeconomic development
of the community.16 Beyond this, improving the accessibility and
comprehensiveness of the obstetric critical care in the peripheral
areas where connectivity is a problem would go the long way in
minimizing maternal and fetal mortality in our country. And it is
also being emphasized that obstetric hemorrhage being still an
important cause, bringing up blood storage facilities at peripheral
centers would have a significant positive impact on reducing the
MMR.7 Montgomery et al. also emphasized lack of facilities in rural
areas and resultant high maternal mortality there.17 Poor transport
facilities and referral delays have been very well known additional
factors contributing to high maternal mortality.18 In this IJCCM
issue, Miglani et al. have highlighted the different levels of delays
including the pre- and intrahospital delays and their impact on
fetomaternal outcomes. So, these delays have to be curtailed by
multilevel efforts to educate all concerned and will include a big
chain of people and agencies involved.
Once the patient reaches the tertiary care center, there may
not be focused and special care for these critical obstetric patients
and there is a concern raised for the special obstetric medical
emergency team (O-MET).18 Most of the tertiary care hospitals have
blood banks but necessary massive transfusion protocols may not
be in place. Besides, hypothermia in massive blood transfusion is
often neglected and needs priority and attention right from the
beginning. Aggressive invasive hemodynamic monitoring will be
essential to have precision in intravenous volume administration
and vasopressor management. All the components of the triad
of death, i.e., acidosis, hypothermia, and coagulopathy, need
anticipation and timely intervention to evaluate and manage
aggressively. The concept of obstetric ICU has been proposed long
back but has not yet been accepted at most of the hospitals. As a
1006 Indian Journal of Critical Care Medicine, Volume 24 Issue 11 (November 2020)
part of promoting the concept, we may need added efforts to train
our obstetrician friends in critical care. Finally, managing critically
ill obstetric patients is teamwork by an emergency intensivist,
obstetrician, anesthesiologist, radiologist, and of course the nursing
staff! Multiple shortfalls have been noted in the management of
such a patient. Understanding the comprehensive meaning of
shock status beyond a reading of low blood pressure (BP) is essential
as it is a systemic disorder with a wider impact on multiple systems.
With the rising prevalence of ICU admissions of hypertensive
disorders of pregnancy patients, we need due attention to manage
the special issues related to this. The timely decision of the cesarean
section or the surgical intervention for obstetric hysterectomy in
hemorrhage cannot be emphasized more. There have been delays
in optimizing such patients and obtaining informed consent for the
life-saving interventions. A senior team needs to be instrumental
in executing these urgent tasks.
Multiple interventions, besides, endometritis and urinary tract
infections do raise the possibility of severe sepsis which remains
an important contributor to the high maternal mortality and
preventive and therapeutic measures need good attention.
Recent advances like the availability of bedside ultrasound/
echocardiography, thromboelastography, advanced imaging,
vascular interventions, and newer wide-spectrum antibiotics, etc.,
have shown a favorable impact on the fetomaternal outcome.
We will need comprehensive global efforts to reduce the global
MMR to 70 per 100,000 live births by 2030, as planned by the United
Nations in its expanded goal.19
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